Healthcare Delivery Organizations

The leaders of hospitals, medical groups, health systems, and other direct delivery organizations can take several steps that would remove obstacles to teamwork and promote it. Chapter 18 presents many of the steps. To summarize, the actions divide into the categories of cultural change, structural change, and targeting of support resources to teams. Cultural changes include emphasizing teamwork values, making teamwork highly visible, and relating effectively to clinicians. Structural changes include designing the organization around teams, assuring team accountability, building connections among teams and between teams and external entities, and altering compensation models for clinicians so that payment provides incentives for teamwork instead of discouraging it. Key resources for teams are information and communication support, support for performance evaluation and education, and qualified and accountable team sponsors.

Health Professional Education

At present, almost all medical schools, nursing schools, and other healthcare educational institutions are working actively against teamwork by educating their students separately from students in other professional schools. By the time students have been in training for 2 years or more, they have developed a sense of identity with their own profession, have embraced the values characteristic of that profession, and have acquired a subtle tribal mindset, which includes wariness and sometimes antagonism to individuals with different professional identities and values. Chapter 3 reviews this process and its consequences in more detail.

The walls between healthcare professional schools need to come down. From the outset of professional education, the value of interprofessional teamwork needs to be stressed. Students need to learn in teams that resemble the teams in which nurses, physicians, pharmacists, social workers, administrators, and other healthcare professionals practice their professions in the day-to-day world of healthcare delivery. It is apparent that teaching students in this way is difficult because it has been achieved so seldom. Professional rivalries, long-held traditions about how to teach certain subjects (for example, interviewing of patients), and mundane considerations such as scheduling of classes all interfere with developing interprofessional education. Still, the obstacles can be overcome as is proven by the programs that have been developed at several universities in the United States and around the world (Meads and Ashcroft, 2005, pp. 135-149; Roethel, 2012).

Professional schools also need to teach principles of teamwork directly. This can be done by interspersing didactic sessions and reading with interprofessional team experiences that are parts of clinical curricula. Discussion of case studies can aid in making the principles fully understood, memorable, and useable by students. Substantial investment in new research is needed to develop the evidence base for cost-effective ways to provide such education (Reeves et al, 2008).

Accrediting organizations for health professional educational programs are potential drivers of transformation. Accrediting organizations can work to infuse interprofessional education competencies within profession-specific accreditation requirements (Royeen et al, 2009, p. 445).

Infrastructure investment funding often is necessary for such efforts. The US Health Resources and Services Administration in 2012 provided 5-year funding for a National Center for Interprofessional Practice and Education, housed at the University of Minnesota (University of Minnesota, 2012). The Macy Foundation, Robert Wood Johnson Foundation, Gordon and Betty Moore Foundation, and John A. Hartford Foundation joined the federal government in supporting the new center. Continuing leadership by private foundations and government agencies for infrastructure development is critical to accelerating progress.

The IOM (2003) recommended refashioning healthcare education so that students are prepared to work in interprofessional teams that are focused collectively on the values, preferences, and needs of patients. Moreover, the report called for educational planning to be done in an interprofessional context so that the walls between professional schools are more likely to be removed. This call is some 10 years old. Although some progress has been made, as indicated earlier, much more is needed.

Health Professional Societies

In recent years, many professional societies and associations, including the American Academy of Family Physicians, the American Association of Nurse Practitioners, the American Medical Association, the American Nurses Association, and the American Pharmacists Association, have engaged in energetic promotion of the interests of their members in a manner that inhibits the development of interprofessional teamwork. While it is not surprising that the societies would advocate for their members, the tone of the rhetoric issued by some of the societies is inflammatory (American Academy of Family Physicians, 2012a; American Association of Nurse Practitioners, 2012). Although all of these associations endorse interprofessional practice in general terms—sometimes using different terms such as multidisciplinary practice, transdisciplinary practice, and interdisciplinary practice—the rhetoric of some of their public statements strongly suggests serious misgivings.

If interprofessional practice is to be broadly understood, trusted, and promoted, the societies will need to soften the tone of their more strident pronouncements and begin trying to seek common understandings. This road will not be easy. Obviously, there are economic concerns underlying some of the disagreements. But there are also legitimate professional points of view at stake. Patients’ interests will be served by these societies seeking to understand each other’s interests and points of view—all of them—and negotiating collaborative agreements that enable all healthcare professionals to contribute to the care of patients using all of their knowledge and skill in interdependent practice. For example, it would be helpful for a group of societies representing practicing nurses, physicians, pharmacists, social workers, and administrators to negotiate a model of collaborative practice and issue a joint statement describing the model. Some will say that such a venture would be naive. It is worth trying.

Health Insurance Companies

Fee-for-service payment of individual clinicians interferes with teamwork. Health insurance companies primarily pay practitioners and healthcare institutions on a fee-for-service basis. It is understandable that institutions use these payments as the basis for paying individual clinicians, paying individuals a percentage of the revenue received for each individual’s services. Some healthcare delivery organizations have severed this linkage, using salaries to pay their clinicians instead of paying them a percentage of the fee-for-service billings they generate. But these organizations are few, and severing the linkage has occurred mainly in very large organizations with multiple sources of revenue.

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